Political change is a double-edged sword for healthcare. Some of the big challenges affecting the sector, as well as some of the sources of dynamism, arise from decentralisation. Since the fall of Suharto’s authoritarian government in 1998, political and fiscal decentralisation has produced a complex set of challenges for health programming. On the one hand, decentralisation of health services creates opportunities for visionary local leaders to develop targeted healthcare programs for their electorates. But it has also made the system vulnerable to local power politics and unchecked corruption, and perpetuates the divide between rich and poor regions.

Inaccurate or late diagnoses, inadequate facilities and treatment, costs that are beyond reach: all of this is part of the daily experience of healthcare for millions of Indonesians. As a result, every year, countless citizens of the country die from conditions that should have been prevented or cured. This special edition of Inside Indonesialooks at the problems that beset healthcare, and searches for signs of hope amidst the political changes that are remaking Indonesia as a more democratic society.

Our articles explore the social and political forces that have generated such uneven outcomes for Indonesia’s health sector during the nation’s transition to democracy. While Indonesia’s economy is growing fast, the government continues to spend less on healthcare per capita than its neighbours with a similar economic profile; key health indicators – like the ratio of health providers to population – are also lagging. All the articles in this edition address the complex question of ‘what is holding Indonesia back?’ What motivates elected officials, health professionals and consumers to make the decisions they make? And what are the outcomes for Indonesia’s most vulnerable communities?

The lead article by Elisabeth Pisani, an epidemiologist and long-time observer of Indonesia’s health system, describes the varieties of dysfunction that plague the sector: from absenteeism in health clinics to the breakdown in critical information sharing between districts and the centre. Pisani blames skewed political incentives for much of this dysfunction. For example, elected local officials invest in expensive and conspicuous health infrastructure to boost their political profiles, rather than addressing more complex healthcare needs. But the democratic transition has also brought positive change. Pisani points to how direct elections put pressure on local politicians to answer their constituents’ demands for better health services. As people’s expectations rise, she hopes, so too will the quality of care.

Edward Aspinall and Eve Warburton analyse the relationship between electoral politics and the rise of local healthcare schemes. Populist campaigns that promise free healthcare are now commonplace in district and provincial elections around the country. This trend reveals how local politicians are engaging with the demands of their electorates in new and progressive ways. Even if the costs of healthcare are coming down for many people, however, this does not always mean that quality is improving.

Reproductive health activist, Inna Hudaya, offers insight into the plight of young women experiencing unplanned pregnancies. She explains how social stigma and discriminatory laws force women into the dangerous, traumatising and sometimes fatal world of illicit abortion. In this case, too, politics plays a role, but it is a politics of social conservatism that denies women control over their bodies. Thankfully, new organisations run by people like Inna are struggling to change discriminatory laws and to help women find the information and services they need.

Andrew Rosser provides an analysis of the political war between anti-tobacco activists and Indonesia’s powerful tobacco lobby. Health laws are slowly changing in response to a strong campaign by the anti-smoking movement, but the tobacco lobby has money and, consequently, friends in high places. It is launching a counter-attack, but a growing number of Indonesians are becoming aware of the huge toll that smoking exacts every year.

Medical anthropologists Byron Good, Mary-Jo DelVecchio Good, and Jesse Hession Grayman present a detailed account of one of the most neglected areas of healthcare in the country: mental health services. Though the situation is in many respects terrible, their experience working on mental health programming in post-conflict and post-disaster Aceh gives hope that a new model of care is emerging.

Still in Aceh, Catherine Smith explores the world of medical tourism in her piece about Acehnese who travel abroad to Malaysia in search of better quality care. The trend not only points to the limitations of local health services, but also reveals how many Acehnese deeply distrust the Indonesian medical system as a whole.

Finally, in a close examination of the problems posed for disease control by political decentralisation, Scott Naysmith looks at the challenges of managing the spread of avian influenza in a context of fragmented governance. Indonesia cannot return to the days of top-down, authoritarian disease eradication, as was practised during the smallpox eradication program under Suharto. Even so, his analysis shows there is an urgent need for more cooperation between districts, provincial administrations and the central government.

Politics is reshaping healthcare in Indonesia. Often it seems that most of the changes are for the worse. Each of our stories, however, provides at least some signs of hope, if only by pointing to how members of the public, health workers and activists are making new demands for better healthcare in the context of democratic politics. One thing is clear: Indonesians deserve much better.

Eve Warburton (evewarburton@gmail.com) is a research assistant at the Department of Political and Social Change, Australian National University, and administrator of the Sydney Southeast Asia Centre, University of Sydney. Edward Aspinall (edward.aspinall@anu.edu.au) researches Indonesian politics at Australian National University and is an editor of Inside Indonesia.